QUESTIONS AND ANSWERS: A Case of Mysterious Pulmonary Disease in an Anorexic Patient

Q. One of my patients with AN, who continues to be severely malnourished, now has a number of suspicious pulmonary symptoms, including coughing, fatigue, and chest pain. She has a long history of AN. I am wondering if there are other issues to consider.

A. Could this be tuberculosis? While reports of eating disorders and development of tuberculosis (TB) are rare, your patient sounds very much like a woman described in a recent report from Francesco Garaci and colleagues at Tor Vergata University in Rome (Radiology Case Reports14. 2019, 423). Dr. Garaci and co-workers reported a case of a 31-year-old woman who had a long history of AN and BN, who was admitted to the gastroenterology department of their hospital for compromised general overall conditions and severe protein-energy malnutrition. Over the last 6 months, she reported losing more than 15 kg (33 lb) and had a body mass index (BMI) of 12. She was fatigued, but did not have a fever.

After she agreed to the tests, CT scans showed multiple lesions. After this, a sputum test showed Mycobacterium tuberculosis(the bacterium that causes tuberculosis).  The patient was immediately placed on a four-drug regimen of isoniazid, rifampin, ethambutol, and pyrizamide. Five weeks later, the patient was able to return home to continue drug treatment.

Tuberculosis is one of those diseases that seem to have been eradicated, but in September 2018, The World Health Organization reported that tuberculosis (TB) is one of the top 10 causes of deaths worldwide, and that in 2017, 10 million people fell ill with TB, and 1.6 million died from it (including 0.3 million among people with HIV). In 2017, an estimated 1 million children became ill with TB, and 230,000 children died of TB (including children with HIV-associated TB).

The situation in the US and other westernized countries has been much better, even though concern about TB has been reemerging lately, due to increased immigration and travel to areas where the disease is still endemic. As the Centers for Disease Control and Prevention’s Morbidity and Mortality Report(MMWR. 2019. 68:257) notes, since 1993, the number of cases of TB has steadily declined.  TB incidence in 2018 (2.8 cases per 100,000 persons) was the lowest ever reported. Non-US-born persons accounted for approximately two-thirds of cases. In 2018, 9,029 new tuberculosis (TB) cases were reported in the US, representing a 0.7% decrease from 2017.

TB remains an important infectious disease problem. AN may impair immune response and could increase risk for various infections, including TB.

– SC

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